Basic Information
| Provider Information | |||||||||
| NPI: | 1821656034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROSPECT CHARTERCARE SJHSRI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HIGH SERVICE AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109434500 | ||||||||
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| Address1: | 200 HIGH SERVICE AVE | ||||||||
| Address2: | |||||||||
| City: | N PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109434500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2019 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | ELDERS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JON | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7147881249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.